We begin with an examination of the programme
itself. This section focuses on those important aspects of programme design
that have been found to have a significant impact on programme performance. You
are asked to examine the programme design to assess the following:

Ideally you need to talk to the persons who
formulated the programme, or at least to senior programme staff, and examine
the programme document and relevant files.

Broad causes of malnutrition such as ‘poor diet’
are not especially helpful: you need to know in what way the diet is poor. You
also need to know why the diet is poor.
Answers to these questions should have guided the nature of the interventions undertaken by the programme.

Planning the programme (problem analysis, selection and design of interventions) should
have taken place in a participatory fashion, working closely with the
programme's target communities. If it did not, not only are errors in analysis
and design more probable, but also the target communities are unlikely to have
any sense of ownership or involvement.

Ultimately all nutrition programmes must aim to improve nutritional status (reduce
wasting, stunting, obesity or micronutrient deficiencies, as appropriate) and
this improvement must be measurable using accepted indicators, such as anthropometric
status and/or biochemical indicators of micronutrient status. Improving nutritional status must be the
primary goal or objective of any comprehensive, national nutrition programme.
All objectives need to be relevant, specific, measurable, realistic and
time-bound4. It is against its objectives that a programme's success or failure is
evaluated.

Many smaller or focused programmes set objectives that relate only to one or a few
of the impediments to improving nutritional status. For example, a programme
may aim to improve nutritional knowledge. This is an intermediate objective,
addressing one impediment to improving nutritional status. Improving nutrition
knowledge will only lead to better nutritional status5
if it is accompanied by, for example, improved child feeding practices, better
access to food, and activities to reduce morbidity, as appropriate. The primary
objective of improving nutritional status must therefore be accompanied by a
set of intermediate objectives that address the specific causes of malnutrition
in the programme's catchment area.

A nutrition programme will benefit by setting also objectives relating to
community participation, improving the macro and microenvironment, and building
capacity. Setting such objectives will
ensure that these important issues are not forgotten during the implementation
of the programme.

Here are the questions you need to answer to assess the programme's relevance:

Was any form of problem analysis undertaken before
the programme was designed? If so, is
there evidence that a participatory approach was used for the problem
analysis? How specific are the causes
of malnutrition identified by the problem analysis?

Does the programme have clear, realistic, relevant, measurable and time-bound objectives? Are there objectives relating to:

- Nutrition?
If so, do they address the causes of malnutrition identified in the
problem analysis?

Targeting is a mechanism to ensure that the
programme reaches only those beneficiaries for whom it is intended. Good
targeting can reduce costs because resources are not wasted on beneficiaries
who do not need the programme interventions.

Targeting can take the
form of geographical targeting (to depressed areas, or areas with particular
agricultural or climatic problems), of socio-economic targeting (to low income
areas of cities, or to households that fall below a specified poverty line,
poor elderly people or landless households), or of vulnerable group targeting
(to weaning-aged children, single mothers or elderly people for example).

If the programme is
targeted to specific beneficiaries, you need to find out if the programme is
failing to reach the intended beneficiaries (undercoverage), or if it is
including beneficiaries who do not meet the selection criteria (leakage):

Are programme activities targeted to specific households, communities or areas? If so, what are the criteria for inclusion in the programme?

If the programme is targeted, is the system working?
Is the programme reaching all the intended beneficiaries? Are beneficiaries
included who do not meet the selection criteria?

On targeting

“Targeting can take various forms: geographic targeting, such as found in the Kenya project (arid and semi-arid lands) or the Honduras project (focus on an area with a specific environmental problem); vulnerable area targeting (targeting to areas where the density of poor communities is high); or socio-economic targeting (selection of households below a poverty line, such as found in the Samurdhi programme). In the Mexico programme a more elaborate dual form of targeting was employed: vulnerable area targeting to select programme localities, then socio-economic targeting to select participating households.

Good targeting can save resources, on the other hand elaborate screening procedures entail unnecessary bureaucracy and high administrative costs (for example, the case of Mexico). They are also open to political manipulation ......... and corruption.”

Programme interventions must address the
causes of malnutrition identified by the problem analysis. They need to meet the objectives of the
programme, within the specified time-frame, and be as cost-effective as
possible, bearing in mind issues of equity. Costs borne by the communities, in
terms of both material resources and time, must be considered. You should
consider too that the most cost-effective programme is not necessarily the most
sustainable, nor is a programme that is cost-effective in the short-term,
necessarily cost-effective in the longer term. Consider a clinic-based vitamin
A supplementation programme, for example, in comparison with a food-based
approach that attempts to improve consumption of vitamin A rich foods. The
supplementation programme will be more cost-effective in the short term, but
the food-based approach will not only be more sustainable, but in the long run
may prove less costly6.

There is now a
considerable body of literature on experiences of nutrition interventions
worldwide. This presents an excellent resource and should be consulted at the
programme formulation stage, to help select the most appropriate and
cost-effective programme design. Interventions must not only address the causes
of malnutrition in the programme area, they must also be based on the most
up-to-date scientific knowledge (see footnote 30), they must engage all
appropriate sectors and they must take into account local resources,
conditions, food availability and cultural practices.

You should check that
the interventions undertaken by the programme do not contradict the services
that are offered to the communities. An example of this would be a programme
that distributed infant formula, while the local health center attempts to
promote breastfeeding. The programme should reinforce rather than undermine the
activities of the local health and agricultural authorities, provided these are
indeed appropriate.

No programme will meet its objectives if the quantity and intensity of resources
allocated are inadequate. Here are some examples:

- A one-off short course to improve nutrition knowledge is
unlikely to be sufficient to change behaviour:
it needs re-enforcement.

- Community mobilizers or health workers with too many families
to cover cannot provide the intensive support needed to achieve change.

- Micronutrient
supplementation or food supplementation needs to be provided at a sufficiently
high level to achieve the intended improvement in nutritional status.

This
subcomponent asks you to assess the extent of community participation, whether
staff have been adequately trained in the participatory approach and how it has
been used and supported in the implementation of community activities.

Community participation in nutrition programmes is now accepted as a key
prerequisite for success and sustainability. The aim of the participatory
approach is to assist communities to become more self-reliant, with the
capacity to analyse their own food and nutrition situation, identify their
needs, plan activities to address these needs, secure funding and technical
expertise, and implement and manage the activities. Achieving a fully
participatory approach, whereby communities have a true sense of ownership of
the programme, demands considerable investment of time and resources. However,
once achieved, it can be maintained at little cost to the programme, provided
that communities continue to have access to adequate basic services (health,
nutrition, agricultural extension services, for example), technical expertise
to help in their selection and design of activities, and funding support for
their activities.

On community participation

“A community-based nutrition programme is not necessarily one that employs a participatory approach. Most people-oriented programmes today will naturally mention community involvement in some form ..... However, few community-based nutrition programmes are truly participatory in nature, engaging communities in decision-making and the selection of activities to answer their felt needs.”

Quoted in FAO's in-depth study of nine programmes (2003).

Participation ranges
from passive participation to full community mobilization. To assess the degree to which the programme
has achieved a participatory approach, you are asked firstly to assess where in
this range the target communities of your programme fall. Secondly, you are
asked to assess whether programme staff are adequately trained in the
participatory approach.

Harnessing local cultural practices and knowledge

FAO's in-depth study of nine programme (2003) found that:

Communities possess a wealth of knowledge and experiences that
can be harnessed to become a part of the programme. In Honduras, the project
was in fact built around a soil conservation technique developed in the village
of Quesungual. Communities that have lived with food insecurity have developed
a number of coping stategies to improve their chances of survival. Many of
these can be retained and supported. Local cultural practices, such as Zunde
raMambo in Zimbabwe, offer entry points and strategies that are more
acceptable to communities than unfamiliar, externally-imposed strategies.
In Kenya the tradition of women's groups and regular community meetings was
used by the project to encourage participation

Visit a representative range of communities, observe community meetings in progress and
have discussions with community leaders and community members. Make sure you
meet the most vulnerable members of the community, to assess the extent of
input they have had in decision-making.

Ask the following questions:

Does the programme work with active, representative community action groups?
Community groups should meet regularly, have well-defined plans, priorities and
activities. They should include representation from all sections of the
community and women must be active members.

Is the programme-building capacity in the community? What training has been
provided and what skills have been acquired (e.g. management, conducting
meetings, planning)? What additional
training needs are there?

Do communities have access to funding and technical advice for their identified
projects/activities?

Has the programme made use of appropriate cultural
practices?

Then situate the communities within the following
range:

Levels of Community Participation

Participation Level

Characteristics

1.

Passive

People are told what is going to happen, or participate by answering questions only.

2.

Consultative

People express their views, which may be taken into account, but have no share in decision-making.

3.

For material incentives

People participate in activities in order to receive food, cash or other incentive. Still no decision-making, and participation often ends when incentives end.

4.

Functional

People form groups and carry out activities to meet objectives of project, but no involvement in choosing objectives, and minimal involvement in choosing activities. Some groups may in time become stronger and more self-reliant.

5.

Interactive

People participate in joint analysis and planning, joint decision-making, with project staff.

6.

Self-mobilization

People take initiatives independent of project staff. They develop contacts with external institutions to access technical expertise and funding, but retain control over decision-making.

Another method
of assessing the extent of community participation is to measure participation
in five key areas: needs assessment, leadership, organization, resource
mobilization, and management. To do this we suggest you use the ‘spidergram’
approach described in S. Rifkin and P. Pridmore: “Partners in Planning” (see
Annex 2 for full reference). Details of how to use this method are reproduced
in Annex 4.

Now
organize a few focus group discussions with programme staff from different
levels and different regions covered by the programme, to ask the following
questions:

Do you think communities can identify their own needs, and plan and implement
activities to meet their needs? If not,
why not?

What training have you received in the participatory approach?

What additional training do you feel you need?

Based on your
observations and discussions, you should begin to have a good idea of the programme staff's perceptions of community
participation. This information will help you decide whether additional
training is needed.

You should now
be able to answer the following questions:

What is the level of participation achieved by the
programme?

How adequate was the training in community
participation received by programme staff and their understanding of the
approach?

Has the programme encouraged community organization,
self-reliance and empowerment?

Community mobilizers7
are an essential part of any project that employs a participatory approach.
Some are paid by the programme, by local authorities or by the communities
themselves. Others are volunteers, generally serving their own community only.
Paid mobilizers are often responsible for a number of communities. Some
programmes also have supervisors who monitor the work of a number of mobilizers
or volunteers. Whatever the system, community workers, whether paid or unpaid,
play a crucial role in community development and programme delivery. The
success or failure of the programme relies heavily on their performance.
Unfortunately, their selection, training and supervision are often given scant
attention. Broadly, mobilizers must have strong technical support and
supervision, but must also be accountable to the community they serve.

Another aspect
that needs attention is the career aspirations and expectations of community
workers. We tend to assume that having identified and recruited the workers,
they will be willing to undertake the same work for the same pay for an
indefinite period of time. Inevitably, dissatisfaction sets in and work
performance falls off.

A method to identify community mobilizers

“[In Thailand] ..... mobilizers are identified and recruited
as a result of a sociogram process, where the individual members of a cluster
or neighbourhood in a community are asked whom, among their neighbours,
they find trustworthy, someone that they tend to consult when they need
advice about a particular problem. These individuals can be recruited to act
as “resource” persons for their 10 or so households*. These
volunteers have a relationship of trust with the households, so that their involvement
in addressing problems of nutrition is an extension of their natural disposition.

There are ways around this: a basic career and salary structure, training
opportunities, regular feedback to highlight achievements, public recognition
and awards8,
and additional responsibilities. Field visits for observation are essential to
assess their role and effectiveness, as well as focus group discussions with
a sample of community groups and discussions with mobilizers and with
supervisors, if these exist. Here are
the questions that need to be answered:

Have mobilizers received any training in community
participatory methods? In leadership
and group dynamics? Are they effective in the communities?

Is there a system of accountability? If so, to whom
are mobilizers accountable and does the system work?

Can they help communities secure funding for their
selected activities? Do they know when and where to seek technical expertise9?

Is their workload manageable? Are they well supervised? Do they receive any feedback on their
performance?

How are they rewarded? Are they paid? If so, by
whom10? Is there any system of social recognition or
motivation?

Are there opportunities for advancement? Is there a
programme of workshops or further training opportunities, when they can also
interact with other mobilizers?

“A key constraint in the project's performance towards attaining its objectives has been the great shortage of community support staff with appropriate training and skills and the lack of institutions able to facilitate and sustain the development processes required…. This has meant that not only the community action planning process, but also project-supported activities in the agriculture and health/nutrition sectors, have been poorly conducted ….”

The challenge with good
management is to establish a structure that promotes transparency, that defines
roles and responsibilities clearly, that permits quick response and limits
bureaucratic formalities but that at the same time is able to check misuse of
programme resources. Perhaps one of the most important features of good
management is the ability to maintain a committed and motivated staff. For
this, frequent feedback is needed and a recognition of achievement and good
performance.

Through an
examination of programme reports and discussions with programme staff at all
levels, answer the following questions:

Is there an adequate management system? Is support and supervision adequate?

Is the staff committed and motivated? Are there well-defined roles, job descriptions and lines of responsibility?

Does the programme demonstrate financial transparency? Are programme resources well-utilized and monitored?

All programme planners agree that monitoring
and evaluation is an essential component of
good programme design. Yet few programmes make provision for adequate
monitoring and evaluation. Monitoring and evaluation should be viewed as
an integral part of the programme design. Monitoring and evaluation should
therefore be:

included
in the programme design;

designed
at the start of the programme with advice from a statistician and
epidemiologist;

funded
within the programme budget.

Monitoring and evaluation can be divided
into three parts:

monitoring
(a process management tool);

evaluation (to measure programme performance and impact);

participatory
monitoring (community-based, for the community's use).

The literature
on monitoring and evaluation is extensive. Two such publications are included
in the reference list in Annex 2 (IADB 1997, ACC/SCN 2001).

a) Monitoring

Monitoring is
the periodic and routine collection of information throughout the life of the
programme to determine whether programme delivery is proceeding smoothly. It is
first and foremost a management tool for programme staff, but also provides
essential information to understand and explain the results of programme
evaluation. As a management tool, it
answers questions such as:

Are programme inputs delivered on time, inputs such as equipment, supplements,
funds and training exercises? If not,
why not?

Is coverage of intended programme participants good? This includes, for example,
attendance at antenatal clinics or growth monitoring and promotion (GMP) sessions.
If not, why not?

Are community mobilization activities proceeding on
schedule? Have community groups been established, do they meet regularly, have
they developed action plans, are they implementing activities? If not, why not?

Information should also be recorded on external events that can affect programme impact.
This includes events such as drought or floods, civil disorder, the state of
roads and bridges. As a management tool, there are two other important aspects
of programme monitoring:

There must be a
system of rapid response to identified problems;

There must be a system of information flow.

b) Evaluation

Evaluation attempts to determine and document, as
systematically and as objectively as possible, the relevance, effectiveness and
impact of a programme in the light of its objectives. Appropriate indicators11
must be identified, an epidemiologist must contribute to evaluation design and
a statistician to data analysis. Both qualitative and quantitative information
are important components of a good evaluation system.

c) Participatory monitoring

The information provided by a programme's monitoring and evaluation system is
largely of little interest to communities. What they need is a system to
monitor their own progress towards achieving their own specific developmental
goals. For this, it is recommended that community groups be encouraged to
establish a simple system of participatory monitoring that relates closely to
their own identified priorities and activities. Examples of simple community
monitoring tools include:

a chart showing the growth of community children;

a community map showing, for example, which households
have built latrines, established kitchen gardens or participated in credit
schemes;

the community action plan indicating the status of
activities.

To decide if the programme has an adequate
monitoring and evaluation system, answer the following questions:

Does the programme have an adequately-funded
monitoring and evaluation system?

Are monitoring reports scrutinized? Is feedback provided to programme staff?

Is there evidence of timely response to monitoring
information on bottlenecks and other operational problems?

Has statistical and epidemiological advice been
sought in the design of the evaluation system?

Are the indicators in line with the programme's
objectives? Has evaluation been
implemented as scheduled?

Does the evaluation data allow assessment of
programme impact?

Have the communities designed and implemented a
participatory monitoring system that relates to their specific development
priorities12?

No programme can
function well in isolation. Linkages with subnational authorities are essential
to its eventual institutionalization. Linkages with other programmes and the
establishment of useful partnerships can enrich a programme substantially and
make it more cost-effective. You are asked here to seek information in order to
answer the following questions:

Has the programme established good working relations
with subnational authorities, bodies or committees?

Does the
programme have collaborative linkages with other relevant programmes?

Has the programme established useful partnerships? Partnerships13 with non-governmental organizations, the private sector and with research and training institutions are important to access technical expertise and supplementary funding, especially funding for community activities.

You now have the information you need to make an assessment of the programme design. Turn now to
the Summary Report provided in Annex 1, and answer the questions in Section I.
Then carry out a SWOC analysis.

Programme effectiveness or the extent to which your programme is able to improve
nutritional status in the area covered by the programme will be seriously
undermined if your programme design is flawed. If you judge the programme
design to be poor, then you need to consider whether the programme is worth
continuing, and whether you should not rather formulate a new programme. In any
event, you will need to discuss your options with the programme funders,
especially if the programme is externally funded.

If you have identified some weaknesses, you can take any or all of the following actions,
as appropriate:

Re-formulate programme objectives to
make them relevant, achievable and measurable;

Develop the necessary conceptual
frameworks to ensure that your programme addresses the causes of malnutrition
in the different areas covered by the programme;

Consider targeting, or improve the
system for targeting, as appropriate;

Examine alternative programme designs to
see if any are more cost-effective and appropriate for your situation;

Strengthen community participation by
providing additional training to all staff and by addressing ways and means of
enhancing the effectiveness of community mobilizers;

Find ways to motivate community
mobilizers. Discuss with them how you can improve their job satisfaction: the
problems they face in their jobs, their career aspirations, their response to
the ideas of social recognition schemes and additional training opportunities;

Establish clear guidelines for
community-level activities, covering the following aspects: identifying
suitable community action groups, building community capacity, helping
communities access technical expertise and funding sources, encouraging
inter-community collaboration and the use of appropriate cultural practices;

Introduce a system of monitoring and
evaluation, and secure funding for it, or re-design the existing one. Establish
a system of information flows and use the information for programme management;

Address identified weaknesses in
programme management: simplify if necessary; discuss job descriptions,
responsibilities, career structures and recognition of achievements with staff
and modify as needed; provide (additional) training in management to
supervisors;

Improve
relations with local authorities; establish or strengthen links and
partnerships with other programmes, non-governmental organizations, the private
sector and research and training institutions, as appropriate.

FAO's in-depth study found a number of strengths, weaknesses, opportunities and constraints in the nine programmes it examined:

Strengths:

high level of community involvement;

well-trained and committed community workers;

effective and appropriate community activities;

appropriate use of local tradition and culture;

well targeted (socio-economic or geographic targeting);

good programme management;

good monitoring and evaluation system;

feedback to communities, recognition of achievements, motivation of communities and
community workers;

Weaknesses:

political interference in targeting of programme activities;

operational problems and delays;

limited community participation;

poor community capacity development, or some leaders not used to full potential;

some inadequate or inappropriate community activities;

lack of conceptual framework, leading to root causes of malnutrition not being
addressed, short-term interventions and curative rather than preventive
approach;